切除第11肋的经膈肌胸、腹膜外胸腹联合切口治疗胸腰段脊椎病变

目的介绍一种改良的经膈肌胸、腹膜外胸腹联合切口治疗胸腰段脊柱病变。方法回顾性分析88例胸腰段病变的患者,均采用切除第11肋的经膈肌胸、腹膜外胸腹联合切口,直接暴露胸腰段椎体,施行各类脊柱手术。结果本组手术暴露时间为30~50 m in,病灶清除彻底,螺钉位置理想。术后发生气胸1例,乳糜液漏1例。62例平均随访23个月,无钢板断裂、植骨不融合、脊柱后凸畸形等并发症发生。结论该手术切口对组织损伤小,手术视野好,术后并发症少,适用于胸腰段脊椎病变的手术。     

经骶棘肌腰方肌间隙行胸腰段脊柱脊髓损伤侧前方减压术

目的：寻求胸腰段脊柱脊髓损伤侧前方减压的新入路。方法：利用胸腰段的解剖关系设计经骶棘肌腰方肌间隙入路行胸腰段脊柱侧前方减压术。结果：临床应用１２例,手术时间１～１．５ｈ,从皮肤切口到完全显露椎体出血４０～６０ｍｌ。此入路不切断骶棘肌、腰方肌、腰大肌及膈肌,不会伤及胸膜等。随访３～６个月,基本痊愈４例,显著进步３例,进步５例。结论：经骶棘肌腰方肌间隙行胸腰段脊柱侧前前方减压入路简捷,损伤小,出血少。既能充分减压,又能最大限度保持脊柱的稳定性,还可避免加重脊髓损伤、胸膜损伤等并发症。     

经胸膜外和腹膜外间隙手术治疗胸腰段脊椎病变

目的　介绍一种改良的胸腹联合切口治疗胸腰段病变。方法　回顾性分析了 19例胸腰段病变的患者 ,采用不经胸腔的和不切开膈肌的改良胸腹联合切口 ,直接暴露胸腰段椎体 ,实行各类脊柱手术。结果　采用此手术切口治疗的 19例病人 ,手术暴露时间平均为 33min ,入路时的出血量约 5 0～ 80ml,术后无一例出现胸腔并发症。结论　该手术切口对组织损伤小 ,手术视野好 ,术后并发症少 ,适用于胸腰段脊椎病变的手术     

有限切口腹膜外入路下胸段腰段脊柱前路手术

目的讨论有限切口腹膜外入路下胸段腰段脊柱前路手术的疗效。方法46例患者,年龄为17～70岁,平均41．5岁,行有限切口腹膜外入路下胸段腰段脊柱前路手术。其中爆裂性骨折．29例,结核10例,不稳定滑脱2例,坏死2例,肿瘤3例。结果有限切口腹膜外入路下胸段腰段脊柱前路手术具有良好的手术视野,组织损伤小,骨折骨碎片及病灶组织清除彻底,椎管减压充分,植骨愈合好,无血管损伤等并发症。结论有限切口腹膜外入路下胸段腰段脊柱前路手术具有损伤性小、安全性高、疗效好的优点。     

脊柱侧凸微创技术(完)

5小切口胸腰椎侧凸前路矫形手术 5．1胸腰椎脊柱侧凸前路手术的标准入路T10至腰段脊柱的暴露通常需要经过胸膜外腹膜后入路或经胸腹膜后入路。对于胸腰段脊柱如果没有特殊的禁忌证通常可以采用胸膜外腹膜后入路,因为这种入路创伤较小而且由于没有胸腔引流管术后恢复较快。采取胸膜外入路时,因为胸膜比较薄需要小心地将壁层胸膜从胸壁上分开,避免胸膜的破裂。因为儿童和青少年的胸膜通常较成年人厚,对于幼年患者通常更适于采用胸膜外入路。     

前后联合入路切除胸腰段椎管巨大哑铃形肿瘤的疗效观察

目的探讨前后联合入路切除胸腰段椎管巨大哑铃形肿瘤的临床疗效。方法 2009年1月-2015年3月,采用经后正中入路联合侧前方经膈肌脚、胸膜外腹膜后入路切除胸腰段椎管巨大哑铃形肿瘤12例。男9例,女3例;年龄30~65岁,平均45岁。病程8~64周,平均12.7周。椎管外肿瘤部分位于T12、L1 6例,L1、25例,L2、3 1例;肿瘤大小范围为4.3 cm×4.0 cm×3.5 cm~7.5 cm×6.3 cm×6.0 cm。根据椎管外肿瘤累及的范围与部位,在Eden分型基础上对胸腰段Ⅱ、Ⅲ、Ⅳ型肿瘤在纵向和横向的侵犯范围进行二次评估,横向为b型5例,d型2例,e型4例,f型1例;纵向累及2个节段椎体8例,2个以上节段椎体4例。术后定期随访观察肿瘤切除情况、是否复发及脊柱稳定性等;采用语言疼痛程度分级法(VRS)评价术后疼痛改善情况。结果手术时间150~230 min,平均170 min;术中失血量270~600 m L,平均350 m L。术后切口均Ⅰ期愈合,无切口及胸腔感染等并发症发生。术后组织病理学确诊为神经鞘瘤10例,神经纤维瘤2例。12例均获随访,随访时间6个月~6年,平均31个月。神经症状均明显改善,腰背部无异常酸痛感。复查胸腰段X线片、MRI未见肿瘤残留,随访期间无病变复发及内固定物松动、断裂,脊柱侧弯等并发症发生。患者术前VRS分级为Ⅰ级2例、Ⅱ级8例、Ⅲ级2例,末次随访时恢复至0级10例、Ⅰ级2例,与术前比较差异有统计学意义(Z=—3.217,P=0.001)。结论经后正中入路联合侧前方经膈肌脚、胸膜外腹膜后入路可安全、完整地切除胸腰段椎管巨大哑铃形肿瘤,并可较好地保护胸腰段脊柱稳定性及椎旁肌肉功能,对于复杂分型的胸腰段椎管哑铃形肿瘤可取得较好疗效。     

保护膈肌的小切口胸腰段脊柱侧凸前路矫形

目的:探讨用保护膈肌的小切口行胸腰段脊柱侧凸前路矫形技术的可能性及临床应用效果。方法:胸腰段特发性脊柱侧凸患者17例(男3例,女14例),年龄12～19(平均14.6)岁,术前Cobb角44°～76°(平均56°),其中4例伴有胸腰段后凸10°～18°,其余病例矢状面正常。内固定节段T11～L312例,T11～L43例,T11～L22例。手术时取凸侧在上的侧卧位,在保护膈肌的前提下在膈肌上下各作长约8cm的切口,暴露至脊柱。内固定器械采用CDH。切除椎间盘后在脊椎上置钉。将矫形棒从膈肌角处小洞中穿过,应用去旋转技术完成腰椎前凸化,同时采用凸侧加压技术进一步矫正侧凸畸形。结果:手术时间为210~270min,平均240min,术中出血310～520ml,平均400ml。术后Cobb角4°～16°(平均10°,纠正率为80%),4例胸腰段后凸畸形术后矢状面恢复形态良好。无术中术后并发症,2例出现手术侧下肢皮温升高。随访3～11个月,无内固定并发症,2例出现6°的额状面纠正度丢失。结论:保护膈肌的小切口胸腰段脊柱侧凸前路矫形是可行的,在减少手术创伤的同时能够达到与传统入路相似的临床疗效,没有明显的并发症增加,具有较大的临床实用价值。     

颈胸段脊柱疾病的手术治疗策略

目的探讨颈胸段脊柱疾病的临床特点及手术治疗策略。方法回顾性分析自2007-01—2014-12采用前路、后路或前后路联合手术治疗的83例颈胸段脊柱疾病。19例骨折、11例椎间盘病变、6例肿瘤、5例结核采用下颈椎低位前方入路手术;11例骨折、6例椎间盘病变、5例肿瘤、3例结核经颈前胸骨柄联合入路手术;6例骨折、3例后凸畸形采用颈胸段后方入路手术;6例骨折、2例结核采用前后联合入路手术。结果本组手术时间80~260 min,平均145 min;术中出血量100~3 100 ml,平均780 ml。75例术后获得随访9~62个月,平均26个月。所有患者术后植骨部位均达到骨性融合,骨性融合时间6~12个月,平均8.5个月。所有患者颈胸段脊柱生理力线恢复,无内固定失败等并发症发生。结论颈胸段脊柱疾病发生率低,但手术风险大,手术入路的选择应根据病变的位置、患者的耐受能力以及手术医师的熟悉程度而定,以减少创伤和并发症的发生。     

胸腰段脊柱骨折前路减压与重建的技术改进

目的 针对前路减压Ｋａｎｅｄａ装置内固定方法治疗胸腰段脊柱骨折手术创伤大、失血多、操作复杂和Ｋａｎｅｄａ装置安装不方便等问题进行改进。方法 将Ｋａｎｅｄａ装置的椎体螺钉与螺棒的穿套式结合方式改为卡锁式结合、采用经第１２肋胸膜外－腹膜后入路显露,对手术操作程序和伤椎切除范围进行了改进。结果 ３８例胸腰段脊柱骨折患者手术无获成功。技术改进手术中平均失血量８８０ｍｌ,手术操作时间平均１４０分钟,手术切口     

病灶清除+同种异体骨移植治疗小儿脊柱结核

目的 探讨通过前方入路进行小儿胸腰段脊柱结核病灶清除、取患儿母亲髂骨进行同种异体骨移植的疗效.方法 对8例小儿胸腰段脊柱结核患者采用前方入路,胸膜、腹膜外进入暴露病灶,彻底清除结核肉芽组织、脓液、死骨、病变坏死椎间盘,取同种异体骨(患儿母亲髂骨)移植重建患儿脊柱前柱,术后石膏外固定保护3-6月,正规抗结核1年以上.结果 随访9月至3年,8例植骨均融合,无排异反应发生,无复发、畸形或截瘫加重,无假关节形成.患儿生长发育正常,能够正常生活.结论 前方入路清除小儿脊柱结核病灶,取其母亲髂骨移植重建患儿脊柱前柱,诱导新骨生成,不影响患儿生长发育,疗效确切.     

The endoscopically assisted simultaneous posteroanterior reconstruction of the thoracolumbar spine in prone position.

BACKGROUND CONTEXT: The reconstruction of the anterior column of the thoracolumbar spine has become more common in the last few years, due largely to the unfavorable results of exclusively posterior surgical treatment, which has been associated with a lack of about 10 degrees of kyphosis correction after removal of the instrumentation. The minimally invasive anterior techniques have reduced the morbidity of the anterior approach significantly. PURPOSE: A minimally invasive technique for anterior stabilization of the spine may reduce the morbidity of the open approach. Irrespective of an anterior open or an endoscopic approach, the posteroanterior instrumentation of thoracolumbar fractures requires time-consuming intraoperative maneuvers to change the patient position from prone to lateral. We describe here a standardized anterior endoscopically assisted approach for the segments T4 to L4. This approach allows the patient to remain in prone position. A 4- to 5-cm incision combined with a retractor system is used. STUDY DESIGN/SETTING: In a prospective study, all patients of our clinic who underwent surgery of the thoracolumbar spine between July 1999 and May 2001 were registered. Study criteria were duration of surgery, duration of anesthesia, intra- and postoperative complications. PATIENT SAMPLE: Between July 1999 and May 2001, 42 patients (25 male, 17 female, average age of 41.9 years), who presented with 55 injured spinal levels and underwent surgery of the thoracolumbar spine in prone position, were included. OUTCOME MEASURES: Duration of surgery (posterior/anterior/total), duration of anesthesia, method of instrumentation, intra- and postoperative complications, postoperative hospital stay and radiographs were evaluated. METHODS: Surgery was performed in prone position. A thoracic approach was used for instrumentation of T9 to L2. A retroperitoneal approach was used for stabilization of L1 to L5. Both procedures were endoscopically assisted with a new retractor system (Synframe; Synthes GmbH, Umkirch, Germany). In this manner, only an incision 4 to 5 cm long and a stab incision for the endoscope were required. The whole procedure was performed in prone position without a change of position during surgery. RESULTS: A total of 42 patients underwent surgery following this technique: 14 isolated anterior procedures (median duration of surgery, 181 minutes); 13 simultaneous one-stage procedures (median duration of surgery: 210 minutes) and 15 combined two-stage procedures (median duration of surgery: 90 minutes posterior, 120 minutes anterior, 240 minutes posterior+anterior). In the simultaneous posteroanterior procedures, the anterior instrumentation was performed 20 times using one rod, twice using two rods and in six patients simply by bone grafting. No intraoperative complications were observed. In the postoperative course, one case of pneumothorax, one case of hemothorax and one case of transient intercostal neuralgia occurred. CONCLUSION: The approach to the anterior spine in prone position is feasible by using a self-holding retractor system for the region between T4 and L4. The duration of anesthesia for the one-stage simultaneous procedure was reduced by about 40 minutes, because changing the position of the patient is no longer necessary. The minimal incision, in combination with the retractor system, significantly reduces cost by allowing the use of less expensive instruments and implants. The advantages of the open and the endoscopic techniques are combined, while their disadvantages are minimized. The main advantage of the prone position is the opportunity to access the anterior and posterior spine simultaneously, which is especially helpful in reduction maneuvers.     

一期前后联合入路手术治疗胸腰椎脊柱结核

目的探讨胸、腰椎结核的手术治疗方式。方法42例胸、腰椎结核患者，男24例，女18例；年龄为22～73岁，平均38．2岁。其中胸椎结核11例，胸腰段结核14例，L2以下腰椎结核17例。术前采用四至六联正规抗结核治疗至少3周，所有患者均采用后路椎弓根螺钉系统矫形内固定、椎板间植骨（人工骨），同期行前路病灶清除联合自体髂骨植骨术。前路手术切口根据病变节段分别采用经胸腔入路、胸膜外腹膜外入路、经腹膜外肾切口、经腹直肌旁腹膜外切口及腹正中腹膜外入路。平均手术时间为230min，术中平均出血量为550ml。术后继续抗结核治疗，术后4周下地行走。结果所有患者均获得8～46个月随访，平均24．3个月。全部患者植骨融合，腰背痛症状缓解，神经功能明显恢复，复查血沉及CRP均正常。结论对于非手术治疗效果不佳的胸、腰椎结核患者，采用后路矫形内固定、前路病灶清除植骨的一期手术方式可获得满意的疗效。     

Simultaneously anterior decompression and posterior instrumentation by extrapleural retroperitoneal approach in thoracolumbar lesions

Background:

Anterior decompression with posterior instrumentation when indicated in thoracolumbar spinal lesions if performed simultaneously in single-stage expedites rehabilitation and recovery. Transthoracic, transdiaphragmatic approach to access the thoracolumbar junction is associated with significant morbidity, as it violates thoracic cavity; requires cutting of diaphragm and a separate approach, for posterior instrumentation. We evaluated the clinical outcome morbidity and feasibility of extrapleural retroperitoneal approach to perform anterior decompression and posterior instrumentation simultaneously by single “T” incision outcome in thoracolumbar spinal trauma and tuberculosis.

Patients and Methods:

Forty-eight cases of tubercular spine (n = 25) and fracture of the spine (n = 23) were included in the study of which 29 were male and 19 female. The mean age of patients was 29.1 years. All patients underwent single-stage anterior decompression, fusion, and posterior instrumentation (except two old traumatic cases) via extrapleural retroperitoneal approach by single “T” incision. Tuberculosis cases were operated in lateral position as they were stabilized with Hartshill instrumentation. For traumatic spine initially posterior pedicle screw fixation was performed in prone position and then turned to right lateral position for anterior decompression by same incision and approach. They were evaluated for blood loss, duration of surgery, superficial and deep infection of incision site, flap necrosis, correction of the kyphotic deformity, and restoration of anterior and posterior vertebral body height.

Results:

In traumatic spine group the mean duration of surgery was 269 minutes (range 215–315 minutes) including the change over time from prone to lateral position. The mean intraoperative blood loss was 918 ml (range 550–1100 ml). The preoperative mean ASIA motor, pin prick and light touch score improved from 63.3 to 74.4, 86 to 94.4 and 86 to 96 at 6 month of follow-up respectively. The mean preoperative loss of the anterior vertebral height improved from 44.7% to 18.4% immediate postoperatively and was 17.5% at final follow-up at 1 year. The means preoperative kyphus angle also improved from 23.3° to 9.3° immediately after surgery, which deteriorated to 11.5° at final follow-up. One patient developed deep wound infection at the operative site as well as flap necrosis, which needed debridement and removal of hardware. Five patients had bed sore in the sacral region, which healed uneventfully. In tubercular spine (n=25) group, mean operating time was approximately 45 minutes less than traumatic group. The mean intraoperative blood loss was 1100 ml (750–2200 ml). The mean preoperative kyphosis was corrected from 55° to 23°. Wound healing occurred uneventful in 23 cases and wound dehiscence occurred in only 2 cases. Nine out of 11 cases with paraplegia showed excellent neural recovery while 2 with panvertebral disease showed partial neural recovery. None of the patients in both groups required intensive unit care.

Conclusions:

Simultaneous exposure of both posterior and anterior column of the spine for posterior instrumentation and anterior decompression and fusion in single stage by extra pleural retroperitoneal approach by “T” incision in thoracolumbar spinal lesions is safe, an easy alternative with reduced morbidity as chest and abdominal cavities are not violated, ICU care is not required and diaphragm is not cut.     

改进的侧前方手术径路在胸腰椎爆裂性骨折中的应用

目的 探讨改进的侧前方手术径路减压内固定治疗胸腰椎爆裂性骨折的疗效. 方法 2003年4月至2006年9月利用胸腰段的解剖关系,改进成"L"形肌间隙经椎间孔入路行骨折减压内固定治疗胸腰椎爆裂性骨折,临床应用16例(改进径路组),并将11例经传统胸腹膜外入路(传统径路组)作为对照组,比较两组住皮肤切口到完全显露椎体出血量、手术时间及总出血量、疗效等方面的差异,并观察术中、术后并发症情况. 结果 27例患者于术均获成功.所有患者获得6～26个月(平均13个月)随访.改进径路组从皮肤切口到完全显露椎体的出血量平均为(80.0±56.5)mL,总出血量平均为(450.0±273.1)mL,手术时间平均为(119.0±35.5)min;传统径路组从皮肤切口到完全显露椎体的出血量平均为(350.0±145.5)mL,总出血量平均为(900.1±421.3)mL,手术时间平均为(193.2±48.3)min,两组上述指标比较差异均有统计学意义(P<0.05).两组在Cobb角改善、伤椎前缘高度比值及神经功能恢复差异均无统计学意义(P>0.05).两组术中均无严重并发症发生,无截瘫加重、植骨块塌陷及高度丢火现象,无假关节肜成和内固定失败. 结论改进的"L"形肌间隙经椎间孔径路行胸腰椎爆裂性骨折侧前方减压入路简捷,出血少.既能充分减压,又能最大限度保持脊柱的稳定性,还可避免加重脊髓损伤、胸腹膜损伤等并发症.     

Anterior approach to the thoracic spine

An anterior approach affords the spine surgeon excellent visualization and access to the anterior thoracic spine, the vertebral bodies, intervertebral disks, spinal canal, and nerve roots. This approach is currently used in the surgical treatment of thoracic disk disease, vertebral osteomyelitis or discitis, fractures and tumors of the vertebral bodies, allowing for proper decompression of neural elements and spine stabilization. Over a 10-year period in a single institution, a total of 142 patients with a mean age of 49.6 years underwent anterior thoracic exposure of the spine. The indication for surgery was trauma fracture in 20 patients, malignancy in 35, degenerative disease in 29 and correction of scoliosis in 58. Surgical approaches were determined based on the location and length of spinal involvement, including cervico-thoracic approach (15) thoracotomic approach (85) video-assisted thoracoscopy (10) and thoracolumbar exposure (32). Mean operative time was 334 min (range from 256 to 410 min). There was no perioperative mortality. Thirty-one patients (21.8%) developed postoperative complications. The anterior approach to the thoracic spine is safe and effective and even the presence of complications can be appropriately managed. An adequate preoperative evaluation stratifying the risk and instituting measures to reduce it, accurate surgical planning and careful surgical technique are key to yielding a good outcome and to reduce the risk of complications.     

Anterior Retroperitoneal Lumbosacral Spine Exposure: Operative Technique and Results

We review our two-team operative technique and results of anterior retroperitoneal lumbosacral spine exposure for diskectomy, partial corpectomy, and spinal instrumentation. Seventy-two patients with lumbar spondylosis and associated symptomatic radiculopathy had this exposure between January 1, 2000 and January 1, 2002. A single disc space was isolated in 54 patients. Multilevel exposure was achieved in 18 patients. Main outcome measures included intra- and postoperative complications, blood transfusion requirements, duration of ileus, incidence of erectile/sexual dysfunction, and length of hospital stay. A single small bowel enterotomy and iliac vein laceration, both repaired primarily, were the only intraoperative complications. Perioperative blood transfusions were required in 13 patients (18%). Mean length of postoperative ileus was 3.5 days and average length of hospital stay was 5 days. Postoperative complications occurred in 7 patients (9.7%). These included erectile dysfunction (2), transient unilateral lower extremity paresis (1), acute acalculous cholecystitis (1), femoral vein thrombosis (1), pneumonia (1), and acute myocardial infarction (1). There were no genitourinary or other major vascular injuries. A two-team approach for lumbosacral spine instrumentation via anterior retroperitoneal exposure capitalizes on unique specialty-specific surgical skills. This paradigm facilitates safe lumbosacral spine surgery and major perioperative complications are rare.     

胸腰段脊柱骨折的手术适应证和术式选择

目的探讨胸腰段脊柱骨折手术适应证和术式选择。方法总结2001~2004年71例胸腰段脊柱骨折临床资料,27例椎管占位大于50%,采用前路减压钛网植骨内固定术;44例椎管占位不超过50%,采用后路椎弓根螺钉内固定后外侧植骨融合术。结果前路手术组所有病例均达到骨性愈合,钛网钢板无移位及断裂,椎体高度无丢失。后路手术组椎体压缩畸形及椎体高度均有恢复,但椎弓根螺钉断裂2例,松动1例。结论前路手术减压彻底,植骨融合率高,但操作复杂,创伤大;后路手术简单,操作容易,对椎管占位小于50%者也能起到间接减压作用。应严格掌握手术指征,选择不同术式,做到既能达到治疗效果,又能尽量减少手术创伤。     

The efficacy of anterior spine exposure by an orthopedic surgeon

This retrospective study was designed to document the incidence and types of perioperative complications that occurred with anterior spinal fusion surgery performed solely by an orthopedic spine surgeon. This study is contrasted to previous studies that document complications from anterior approaches performed by an orthopedic surgeon with the assistance of a general or a vascular surgeon. Specifically, the procedures included thoracotomies, thoracolumbar retroperitoneal, and lumbosacral approaches. Our sample consisted of 450 patients who underwent anterior spinal fusion between levels T1 and S1, from 1985 to 1997. Patient and surgery characteristics included age, sex, diagnosis, levels of fusion, blood loss, operative time, hospitalization time, complications, American Society of Anesthesiologists state, assessment of risk factors, previous surgery, and surgical approach used. Average follow-up was 41.69 months, with a minimum of 12 months and a maximum of 132 months. Our results indicated that anterior procedures performed solely by our senior orthopedic surgeon had a lower incidence of complications, less blood loss, and shorter operative time than anterior procedures performed by an orthopedic surgeon and a vascular or a general surgeon. Our findings suggest that the anterior spinal exposure is a safe approach that may be performed solely by a spinal surgeon who is knowledgeable and experienced.     

New instrumentation for video-assisted anterior spine release

Endoscopic surgery in the area of orthopedics has been evolving, particularly in spine surgery. We describe the clinical outcome of thoracoscopic anterior spine release using new instruments. A harmonic scalpel (HS) with a 5-mm hook dissector was used to dissect the spine and rib and to coagulate and transect the vascular bundles. A rib dissector and resector were used for excision of the rib to be implanted in the disk spaces. We treated scoliosis in four patients (three male, one female) with a mean age of 19.5 ± 4.5 years and thoracolumbar kyphosis in a 16-year-old male patient. A mean number of 6.5 ± 2.5 vertebrae with scoliosis and four vertebrae with kyphosis were released. In all cases, division of the vascular bundle and exposure of the spine were completed using only the HS, and excision of a rib segment was performed via a port incision using only the rib dissector and resector. The mean duration of thoracoscopic anterior release was 92 ± 28 min. Blood loss was minimal during and after surgery. Thoracoscopic anterior spine release can be facilitated by the new instruments described above. Received: 8 March 1999/Accepted: 24 September 1999/Online publication: 10 April 2000